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Prof R Shukla(DM,Neurology)
KGMU
Case history
• GCS- 15/15
• Optic nerves-
Visual acuity- PL/PR absent both eyes.
Fundus- Bilateral primary optic atrophy.
• Bilateral 3rd 4th 6th cranial nerves palsy present.
• Right LMN facial nerve palsy present.
Axial Sagittal
Introduction
• Tuberculosis is a major cause of death worldwide.
• Tuberculous meningitis
- Basal and spinal
• Tuberculoma
- Intracranial (parenchymal & extraparenchymal)
- Spinal (parenchymal & extraparenchymal)
• Tuberculous abscess
• Tuberculous encephalopathy
- With or without meningitis
• Spinal cord involvement secondary to skeletal
tuberculosis
Contd…
Classification of neurotuberculosis Contd…
• Intracranial
- Tuberculous meningitis
- Tuberculoma
- Tuberculous abscess
- Tuberculous encephalopathy
- Tuberculous vasculopathy
• Spinal
- Pott’s spine and Pott’s paraplegia
- Tuberculous arachnoiditis
- Spinal tuberculoma
- Spinal meningitis
Causative organism
• Responsive to corticosteroids.
Tuberculoma
• Firm avascular spherical
granulomatous mass.
• Usually 2-8cm in diameter.
• Symptoms related to their
size and location.
• Low grade fever, headache,
vomiting, seizures, focal
neurological deficit, and
papilloedema are the
characteristic.
• Target sign is characteristic.
Spinal tuberculosis
• < 1% of patients.
• Infection starts in cancellous bone
usually adjacent to an inter-vertebral
disc or anteriorly under the Myelitis
periosteum.
• Thoracic (65%) lumbar (20%),
cervical (10%), thoraco-lumbar (5%),
and atlanto-axial region (< 1%).
• Two (<90%), Three (50%) vertebrae
• Paraspinal abscess 55-90%.
• Local pain, tenderness over the
affected spine or a gibbus associated
with paravertebral muscle spasm or a
palpable paravertebral abscess.
• Neurological deficit results from
multiple causes.
Potts spine
Non-osseous spinal cord tuberculosis
Contd…
Tuberculous meningitis (TBM) Contd…
• Meningeal irritation - neck stiffness, Kernig’s sign,
Bickelle’s sign and Brudzinski’s sign.
History
Tuberculosis 55 8-12
Symptoms
Headache 20-50 50-60
Nausea/vomiting 50-75 8-40
Apathy/behavioural changes 30-70 30-70
Seizures 10-20 0-15
Signs
Fever 50-100 60-100
Meningismus 70-100 60-70
Cranial nerve palsy 15-30 15-40
Coma 30-45 20-30
Zuger A. Tuberculosis. In: Scheld WN, Whitley RJ, Marra CM, editors. Infections of
Central Nervous System. Philadelphia: Lippincott, 2004. pp. 441-9.
Staging of TBM
Biochemical
Radiolabelled bromide partition ratio 90-94 88-96 48
CSF adenosine deaminase level 73-100 71-99 <24
CSF tuberculostearic acid level 95 99 <24
Kalita J, Misra UK. Tuberculosis Meningitis. In Misra UK, Kalita J (Eds) Diagnosis and
Management of Neurological Disorders. Wolter Kluwers Health New Delhi 2011; pp. 145-
66.
Sensitivity & specificity of various
diagnostic tests for TBM
Diagnostic test Sensitivity Specificity
ZN staining 10-20% 100%
LJ Culture 15% (25-80) 100%
BACTEC Culture 55% 100%
ELISA 52.3% 91.6%
TB PCR 56% 98%
TST 73% 56%
QTF-GOLD 76% 98%
ELISPOT 87% 92%
Thwaites GE et al. Diagnosis of adult tuberculosis meningitis by use of clinical and laboratory features.
Lancet 2002; 360: 1287-92.
Imaging in TBM
• CT/ MRI confirm the presence and extent of basal arachnoiditis,
cerebral oedema, infarction, ventriculitis and hydrocephalus.
INH Cycloserine
Rifampicin Ethionamide
Rifapentine Levofloxacin*
Rifabutin* Moxifloxacin*
Ethambutol Gatifloxacin*
Pyrazinamide p-aminosalicylic acid**
Streptomycin**
Amikacin/Kanamycin*
Capreomycin
• Others-Ethionamide, prothionamide.
Adjunctive steroid therapy
• Stage of disease.